Bridging the Gaps: Special Commentary
Quantitative sensory testing in predicting persistent pain after joint replacement surgery: promise and challenges Robert C. Coghilla, Francis J. Keefeb
Q
uantitative sensory testing (QST) has deep roots in the history of pain. Mitchell9 in 1864 was routinely testing tactile sensibility and localization in his patients with causalgia. Head and Holmes6 in 1911 employed an elegant array of QST procedures including 2-point discrimination, pressure pain, and thermal pain assessments. By 1959, Noordenbos11 had developed a full battery of sensory tests for the patient with chronic pain that even included temporal summation of pain. Hardy et al.5 spent decades perfecting sensory assessments using carefully quantified noxious heat. Rapid technological evolution resulted in dozens of computer-controlled devices that can rapidly heat and cool the skin,1,22,26 distend the rectum or esophagus,16,20 squeeze muscles,19 and even apply complex patterns of noxious stimuli with lasers.10 Indeed, very few organ systems have escaped noxious stimulation with some form of device or another. A fundamental assumption of QST research is that improved assessment of patients responses to pain will result in an improved ability to predict the outcome of treatments that could lead to better tailoring of therapy to each individual. However, this assumption has been challenging to bring to fruition. Stopping pain before it starts may be crucial. Accordingly, postoperative pain may represent one of the best targets for QST-based individualized treatment because there is a window of time for intervention, either before, during, or after surgery. Some surgeries such as thoracotomies have high incidences of chronic postoperative pain2; therefore, a great deal of suffering could potentially be alleviated if adequate interventions could be developed. Two studies in this issue of PAIN® underscore the challenges and promise of providing better treatment with better categorization. Both studies focus on joint replacement in patients with osteoarthritis. For several reasons, knee and/or hip joint replacement surgery is a particularly good model in which predictive ability of QST can be tested. These reasons include the fact that it is a common surgery, severe pain is one of the key indicators for this surgery, and, although many patients experience significant pain relief, there is a subgroup that continues to experience persistent pain and disability months and years after surgery.
The authors declare no conflicts of interest. a
Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, NC, USA, b Department of Psychiatry and Behavioral Sciences, Pain Prevention and Treatment Research Program, Duke University Medical Center, Durham, NC, USA E-mail address: [email protected] PAIN 156 (2015) 4–5 © 2014 International Association for the Study of Pain http://dx.doi.org/10.1016/j.pain.0000000000000025
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R.C. Coghill, F.J. Keefe 156 (2015) 4–5
In the first of these studies, Wylde et al.27 performed a largescale study examining pressure pain thresholds on the forearm as potential predictors of chronic pain after total hip replacement (N 5 254) or total knee replacement (N 5 239). They found that preoperative pressure pain thresholds were related to joint pain severity both preoperatively and postoperatively. However, preoperative pressure pain thresholds failed to predict the change in total pain, movement pain, or resting pain that was evident 12 months after joint replacement. Similarly, in the second study involving a smaller number of patients (N 5 78), Petersen et al.13 replicated the finding that preoperative pressure pain thresholds did not predict pain at 12 months after surgery. However, their study found that a different QST parameter, temporal summation of repetitive (10) applications of 25.6 g of a mechanical stimulus applied to the affected knee, was significantly related to pain at 12 months after surgery. Across an ever-increasing number of studies, dynamic measures of pain sensitivity such as temporal summation and conditioned pain modulation are emerging as more valid predictors than more static measures such as pain threshold or suprathreshold pain sensitivity.29 In both studies, the choice to examine pressure pain thresholds was clear. Pressure algometers are small, portable, inexpensive, and require minimal training. Accordingly, these devices can easily be used in a busy clinical setting where equipment, space, and time demands can increase costs. Testing of dynamic phenomenon such as temporal summation or conditioned pain modulation invariably requires more equipment, more time, and, frequently, a dedicated QST laboratory with personnel highly trained in the administration of these more complicated stimulus paradigms. Moreover, QST alone only provides part of the picture. For example, there is a growing body of literature demonstrating that psychological factors such as pain catastrophizing,3,15,21,25 helplessness,24 coping strategies,7 perceived injustice,28 and depression and anxiety4,8,17,18 are predictive of pain and painrelated disability in patients with arthritis undergoing knee or hip joint replacement surgery. These findings raise several interesting future research directions. First, investigations need to examine the mechanisms by which such factors influence pain-related outcomes. Studies need to evaluate whether these factors affect pain by enhancing attentional amplification of aberrant nociceptive afferent input, interfering with exercise and behavioral activation efforts designed to enhance a return to normal function, or causing dysfunctional social interactions that can reduce patients’ access to potential sources of social support. Second, many of these psychological factors are potentially modifiable PAIN®
Copyright Ó 2014 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
January 2015
·
Volume 156
·
Number 1
through behavioral interventions, and there is heightened interest in presurgical or perisurgical psychosocial and non-pharmacological interventions that could enhance the outcomes of joint replacement surgery.12,14,23 Early identification of patients at risk for poor outcomes using QST and psychological measures could lead to timely referrals for treatment that potentially could prevent pain and suffering in many patients. Third, studies need to examine how changes in QST that occur over the course of joint replacement surgery affect psychological factors (and vice versa). Such studies could provide important new insights into whether changes in QST parameters precede improvements in psychological factors that affect treatment outcome or whether changes in psychological factors precede improvements in QST parameters. Such information could inform clinical decisions about the timing of assessment and treatment efforts. Multivariate models incorporating all of these factors are needed to develop algorithms to predict both patient outcomes and treatment responsiveness. Moreover, movement away from group-based studies toward a focus on individual outcomes is critical. The sensitivity and specificity of these different algorithms need to be directly evaluated. How well can these models predict the outcome for a single individual? Such information is critical to the development of individually tailored interventions to prevent the development of chronic pain. Finally, the crucial question is: can accurate assessment and prediction actually lead to better treatments and better outcomes? Will a sufficient number of patients be helped by predictions derived from multivariate assessments to justify the clinical costs? Will different procedures provide different windows of opportunity for effective individualized interventions? We are cautiously optimistic that these objectives can be obtained.
References [1] Chen AC, Niddam DM, Arendt-Nielsen L. Contact heat evoked potentials as a valid means to study nociceptive pathways in human subjects. Neurosci Lett 2001;316:79–82. [2] Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term postthoracotomy pain. Chest 1991;99:270–4. [3] Edwards RR, Haythornthwaite JA, Smith MT, Klick B, Katz JN. Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Pain Res Manag 2009;14: 307–11. [4] Hanusch BC, O’Connor DB, Ions P, Scott A, Gregg PJ. Effects of psychological distress and perceptions of illness on recovery from total knee replacement. Bone Joint J 2014;96-B:210–6. [5] Hardy JD, Wolff HG, Goodell H. Pain Sensations and Reactions. Baltimore: Williams & Wilkins, 1952. [6] Head H, Holmes G. Sensory disturbances from cerebral lesions. Brain 1911;34:102–254. [7] Lopez-Olivo MA, Landon GC, Siff SJ, Edelstein D, Pak C, Kallen MA, Stanley M, Zhang H, Robinson KC, Suarez-Almazor ME. Psychosocial determinants of outcomes in knee replacement. Ann Rheum Dis 2011;70:1775–81. [8] McHugh GA, Campbell M, Luker K. Predictors of outcomes of recovery following total hip replacement surgery: A prospective study. Bone Joint Res 2013;27:248–54.
www.painjournalonline.com
5
[9] Mitchell SW, Morehouse GR, Keen WW. Gunshot Wounds and other Injuries of Nerves. Philadelphia: Lippencott, 1864. [10] Morch CD, Andersen OK, Quevedo AS, Arendt-Nielsen L, Coghill RC. Exteroceptive aspects of nociception: insights from graphesthesia and two-point discrimination. PAIN 2010;151:45–52. [11] Noordenbos W. Pain. Amsterdam: Elsevier, 1959. [12] Pellino TA, Gordon DB, Engelke ZK, Busse KL, Collins MA, Silver CE, Norcross NJ. Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty. Orthop Nurs 2005;24:182–90. [13] Petersen GL, Finnerup NB, Grosen K, Pilegaard HK, Tracey I, Benedetti D, Price DD, Jensen TS, Vase L. Expectations and positive emotional feelings accompany reductions in ongoing and evoked neuropathic pain following placebo interventions. PAIN 2014;155:2687–98. [14] Riddle DL, Keefe FJ, Nay WT, McKee D, Attarian DE, Jensen MP. Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Arch Phys Med Rehabil 2011;92:859–65. [15] Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res 2010;468:798–806. [16] Ritchie J. Pain from distension of the pelvic colon by inflating a balloon in the irritable colon syndrome. Gut 1973;14:125–32. [17] Singh JA, Lewallen D. Predictors of pain and use of pain medications following primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years. BMC Musculoskelet Disord 2010;11:90. [18] Singh JA, Lewallen DG. Predictors of pain medication use for arthroplasty pain after revision total knee arthroplasty. Rheumatology 2014;53: 1752–8. [19] Staud R, Koo E, Robinson ME, Price DD. Spatial summation of mechanically evoked muscle pain and painful aftersensations in normal subjects and fibromyalgia patients. PAIN 2007;130:177–87. [20] Strigo IA, Bushnell MC, Boivin M, Duncan GH. Psychophysical analysis of visceral and cutaneous pain in human subjects. PAIN 2002;97:235–46. [21] Sullivan M, Tanzer M, Stanish W, Fallaha M, Keefe FJ, Simmonds M, Dunbar M. Psychological determinants of problematic outcomes following Total Knee Arthroplasty. PAIN 2009;143:123–9. [22] Sumino R, Dubner R, Starkman S. Responses of small myelinated “warm” fibers to noxious heat stimuli applied to the monkey’s face. Brain Res 1973;62:260–3. [23] Thomas KM, Sethares KA. Is guided imagery effective in reducing pain and anxiety in the postoperative total joint arthroplasty patient? Orthop Nurs 2010;29:393–9. [24] Venkataramanan V, Gignac MA, Dunbar M, Garbuz D, Gollish J, Gross A, Hedden D, MacDonald SJ, Mahomed NN, Schemitsch E, Davis AM. The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery. Osteoarthritis Cartilage 2013;21:911–7. [25] Wade JB, Riddle DL, Thacker LR. Is pain catastrophizing a stable trait or dynamic state in patients scheduled for knee arthroplasty? Clin J Pain 2012;28:122–8. [26] Wilcox GL, Giesler GJ Jr. An instrument using a multiple layer Peltier device to change skin temperature rapidly. Brain Res Bull 1984;12: 143–6. [27] Wylde V, Sayers A, Lenguerrand E, Gooberman-Hill R, Pyke M, Beswick AD, Dieppe P, Blom AW. Pre-operative widespread pain sensitisation and chronic pain after hip knee replacement: a cohort analysis. PAIN 2014;156: 47–54. [28] Yakabov E, Scott W, Stanish W, Dunbar M, Richardson G, Sullivan M. The role of perceived injustice in the prediction of pain and function after total knee arthroplasty. PAIN 2014;155:2040–6. [29] Yarnitsky D, Granot M, Granovsky Y. Pain modulation profile and pain therapy: between pro- and antinociception. PAIN 2014;155:663–5.
Copyright Ó 2014 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
Quantitative sensory testing in predicting persistent pain after joint replacement surgery: promise and challenges Robert C. Coghilla, Francis J. Keefeb
Q
uantitative sensory testing (QST) has deep roots in the history of pain. Mitchell9 in 1864 was routinely testing tactile sensibility and localization in his patients with causalgia. Head and Holmes6 in 1911 employed an elegant array of QST procedures including 2-point discrimination, pressure pain, and thermal pain assessments. By 1959, Noordenbos11 had developed a full battery of sensory tests for the patient with chronic pain that even included temporal summation of pain. Hardy et al.5 spent decades perfecting sensory assessments using carefully quantified noxious heat. Rapid technological evolution resulted in dozens of computer-controlled devices that can rapidly heat and cool the skin,1,22,26 distend the rectum or esophagus,16,20 squeeze muscles,19 and even apply complex patterns of noxious stimuli with lasers.10 Indeed, very few organ systems have escaped noxious stimulation with some form of device or another. A fundamental assumption of QST research is that improved assessment of patients responses to pain will result in an improved ability to predict the outcome of treatments that could lead to better tailoring of therapy to each individual. However, this assumption has been challenging to bring to fruition. Stopping pain before it starts may be crucial. Accordingly, postoperative pain may represent one of the best targets for QST-based individualized treatment because there is a window of time for intervention, either before, during, or after surgery. Some surgeries such as thoracotomies have high incidences of chronic postoperative pain2; therefore, a great deal of suffering could potentially be alleviated if adequate interventions could be developed. Two studies in this issue of PAIN® underscore the challenges and promise of providing better treatment with better categorization. Both studies focus on joint replacement in patients with osteoarthritis. For several reasons, knee and/or hip joint replacement surgery is a particularly good model in which predictive ability of QST can be tested. These reasons include the fact that it is a common surgery, severe pain is one of the key indicators for this surgery, and, although many patients experience significant pain relief, there is a subgroup that continues to experience persistent pain and disability months and years after surgery.
The authors declare no conflicts of interest. a
Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, NC, USA, b Department of Psychiatry and Behavioral Sciences, Pain Prevention and Treatment Research Program, Duke University Medical Center, Durham, NC, USA E-mail address: [email protected] PAIN 156 (2015) 4–5 © 2014 International Association for the Study of Pain http://dx.doi.org/10.1016/j.pain.0000000000000025
4
·
R.C. Coghill, F.J. Keefe 156 (2015) 4–5
In the first of these studies, Wylde et al.27 performed a largescale study examining pressure pain thresholds on the forearm as potential predictors of chronic pain after total hip replacement (N 5 254) or total knee replacement (N 5 239). They found that preoperative pressure pain thresholds were related to joint pain severity both preoperatively and postoperatively. However, preoperative pressure pain thresholds failed to predict the change in total pain, movement pain, or resting pain that was evident 12 months after joint replacement. Similarly, in the second study involving a smaller number of patients (N 5 78), Petersen et al.13 replicated the finding that preoperative pressure pain thresholds did not predict pain at 12 months after surgery. However, their study found that a different QST parameter, temporal summation of repetitive (10) applications of 25.6 g of a mechanical stimulus applied to the affected knee, was significantly related to pain at 12 months after surgery. Across an ever-increasing number of studies, dynamic measures of pain sensitivity such as temporal summation and conditioned pain modulation are emerging as more valid predictors than more static measures such as pain threshold or suprathreshold pain sensitivity.29 In both studies, the choice to examine pressure pain thresholds was clear. Pressure algometers are small, portable, inexpensive, and require minimal training. Accordingly, these devices can easily be used in a busy clinical setting where equipment, space, and time demands can increase costs. Testing of dynamic phenomenon such as temporal summation or conditioned pain modulation invariably requires more equipment, more time, and, frequently, a dedicated QST laboratory with personnel highly trained in the administration of these more complicated stimulus paradigms. Moreover, QST alone only provides part of the picture. For example, there is a growing body of literature demonstrating that psychological factors such as pain catastrophizing,3,15,21,25 helplessness,24 coping strategies,7 perceived injustice,28 and depression and anxiety4,8,17,18 are predictive of pain and painrelated disability in patients with arthritis undergoing knee or hip joint replacement surgery. These findings raise several interesting future research directions. First, investigations need to examine the mechanisms by which such factors influence pain-related outcomes. Studies need to evaluate whether these factors affect pain by enhancing attentional amplification of aberrant nociceptive afferent input, interfering with exercise and behavioral activation efforts designed to enhance a return to normal function, or causing dysfunctional social interactions that can reduce patients’ access to potential sources of social support. Second, many of these psychological factors are potentially modifiable PAIN®
Copyright Ó 2014 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
January 2015
·
Volume 156
·
Number 1
through behavioral interventions, and there is heightened interest in presurgical or perisurgical psychosocial and non-pharmacological interventions that could enhance the outcomes of joint replacement surgery.12,14,23 Early identification of patients at risk for poor outcomes using QST and psychological measures could lead to timely referrals for treatment that potentially could prevent pain and suffering in many patients. Third, studies need to examine how changes in QST that occur over the course of joint replacement surgery affect psychological factors (and vice versa). Such studies could provide important new insights into whether changes in QST parameters precede improvements in psychological factors that affect treatment outcome or whether changes in psychological factors precede improvements in QST parameters. Such information could inform clinical decisions about the timing of assessment and treatment efforts. Multivariate models incorporating all of these factors are needed to develop algorithms to predict both patient outcomes and treatment responsiveness. Moreover, movement away from group-based studies toward a focus on individual outcomes is critical. The sensitivity and specificity of these different algorithms need to be directly evaluated. How well can these models predict the outcome for a single individual? Such information is critical to the development of individually tailored interventions to prevent the development of chronic pain. Finally, the crucial question is: can accurate assessment and prediction actually lead to better treatments and better outcomes? Will a sufficient number of patients be helped by predictions derived from multivariate assessments to justify the clinical costs? Will different procedures provide different windows of opportunity for effective individualized interventions? We are cautiously optimistic that these objectives can be obtained.
References [1] Chen AC, Niddam DM, Arendt-Nielsen L. Contact heat evoked potentials as a valid means to study nociceptive pathways in human subjects. Neurosci Lett 2001;316:79–82. [2] Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term postthoracotomy pain. Chest 1991;99:270–4. [3] Edwards RR, Haythornthwaite JA, Smith MT, Klick B, Katz JN. Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Pain Res Manag 2009;14: 307–11. [4] Hanusch BC, O’Connor DB, Ions P, Scott A, Gregg PJ. Effects of psychological distress and perceptions of illness on recovery from total knee replacement. Bone Joint J 2014;96-B:210–6. [5] Hardy JD, Wolff HG, Goodell H. Pain Sensations and Reactions. Baltimore: Williams & Wilkins, 1952. [6] Head H, Holmes G. Sensory disturbances from cerebral lesions. Brain 1911;34:102–254. [7] Lopez-Olivo MA, Landon GC, Siff SJ, Edelstein D, Pak C, Kallen MA, Stanley M, Zhang H, Robinson KC, Suarez-Almazor ME. Psychosocial determinants of outcomes in knee replacement. Ann Rheum Dis 2011;70:1775–81. [8] McHugh GA, Campbell M, Luker K. Predictors of outcomes of recovery following total hip replacement surgery: A prospective study. Bone Joint Res 2013;27:248–54.
www.painjournalonline.com
5
[9] Mitchell SW, Morehouse GR, Keen WW. Gunshot Wounds and other Injuries of Nerves. Philadelphia: Lippencott, 1864. [10] Morch CD, Andersen OK, Quevedo AS, Arendt-Nielsen L, Coghill RC. Exteroceptive aspects of nociception: insights from graphesthesia and two-point discrimination. PAIN 2010;151:45–52. [11] Noordenbos W. Pain. Amsterdam: Elsevier, 1959. [12] Pellino TA, Gordon DB, Engelke ZK, Busse KL, Collins MA, Silver CE, Norcross NJ. Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty. Orthop Nurs 2005;24:182–90. [13] Petersen GL, Finnerup NB, Grosen K, Pilegaard HK, Tracey I, Benedetti D, Price DD, Jensen TS, Vase L. Expectations and positive emotional feelings accompany reductions in ongoing and evoked neuropathic pain following placebo interventions. PAIN 2014;155:2687–98. [14] Riddle DL, Keefe FJ, Nay WT, McKee D, Attarian DE, Jensen MP. Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Arch Phys Med Rehabil 2011;92:859–65. [15] Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res 2010;468:798–806. [16] Ritchie J. Pain from distension of the pelvic colon by inflating a balloon in the irritable colon syndrome. Gut 1973;14:125–32. [17] Singh JA, Lewallen D. Predictors of pain and use of pain medications following primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years. BMC Musculoskelet Disord 2010;11:90. [18] Singh JA, Lewallen DG. Predictors of pain medication use for arthroplasty pain after revision total knee arthroplasty. Rheumatology 2014;53: 1752–8. [19] Staud R, Koo E, Robinson ME, Price DD. Spatial summation of mechanically evoked muscle pain and painful aftersensations in normal subjects and fibromyalgia patients. PAIN 2007;130:177–87. [20] Strigo IA, Bushnell MC, Boivin M, Duncan GH. Psychophysical analysis of visceral and cutaneous pain in human subjects. PAIN 2002;97:235–46. [21] Sullivan M, Tanzer M, Stanish W, Fallaha M, Keefe FJ, Simmonds M, Dunbar M. Psychological determinants of problematic outcomes following Total Knee Arthroplasty. PAIN 2009;143:123–9. [22] Sumino R, Dubner R, Starkman S. Responses of small myelinated “warm” fibers to noxious heat stimuli applied to the monkey’s face. Brain Res 1973;62:260–3. [23] Thomas KM, Sethares KA. Is guided imagery effective in reducing pain and anxiety in the postoperative total joint arthroplasty patient? Orthop Nurs 2010;29:393–9. [24] Venkataramanan V, Gignac MA, Dunbar M, Garbuz D, Gollish J, Gross A, Hedden D, MacDonald SJ, Mahomed NN, Schemitsch E, Davis AM. The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery. Osteoarthritis Cartilage 2013;21:911–7. [25] Wade JB, Riddle DL, Thacker LR. Is pain catastrophizing a stable trait or dynamic state in patients scheduled for knee arthroplasty? Clin J Pain 2012;28:122–8. [26] Wilcox GL, Giesler GJ Jr. An instrument using a multiple layer Peltier device to change skin temperature rapidly. Brain Res Bull 1984;12: 143–6. [27] Wylde V, Sayers A, Lenguerrand E, Gooberman-Hill R, Pyke M, Beswick AD, Dieppe P, Blom AW. Pre-operative widespread pain sensitisation and chronic pain after hip knee replacement: a cohort analysis. PAIN 2014;156: 47–54. [28] Yakabov E, Scott W, Stanish W, Dunbar M, Richardson G, Sullivan M. The role of perceived injustice in the prediction of pain and function after total knee arthroplasty. PAIN 2014;155:2040–6. [29] Yarnitsky D, Granot M, Granovsky Y. Pain modulation profile and pain therapy: between pro- and antinociception. PAIN 2014;155:663–5.
Copyright Ó 2014 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
